Basic Information
| Provider Information | |||||||||
| NPI: | 1043295124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRESNAHAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 317 N EL CAMINO REAL | ||||||||
| Address2: | #210 | ||||||||
| City: | ENCINITAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920242811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606340248 | ||||||||
| FaxNumber: | 7606341782 | ||||||||
| Practice Location | |||||||||
| Address1: | 10225 AUSTIN DRIVE | ||||||||
| Address2: | # 204 | ||||||||
| City: | SPRING VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196704567 | ||||||||
| FaxNumber: | 6196700200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2005 | ||||||||
| LastUpdateDate: | 04/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 14228 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.